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HomeMy WebLinkAbout0082 KERRY DRIVE - Health 82 Kerry Drive Marstons Mills P A = 060 022 tOC •T ION ovye SEWAGE PERMIT NO. VIL-LACE �/1.S,�IJJiJ� ✓�A�� � INSTA LLER'S NAME i ADDREtS �o r% R U I L D E R 0 OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED 13X7 ti. �s � � P TOWN OF BARNSTABLE L-OCAT:bN SEWAGE # 117V�� VILLAGE / . �,�//r ASSESSOR'S MAP & LOT ' _ D9a INSTALLER'S NAME&PHONE NO. /h L uclf&e 2e 11 c_ SEPTIC TANK CAPACITY ld u v LEACHING FACILITY: (ty ) /A/71 7'7'A l 72Wt, ' (size) NO. OF BEDROOMS BUILDER OR OWNER 1 PERMITDATE: D (POCOMPLIA /NCE DATE: o j t Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Famished by I is - a Aad e a1 , COMMONWEALTH OF MASSACHUSETTS I EXECUTIVE OFFICE OF ENVIRONMENTAL AFF=AIR.S'ED DEPARTMENT OF ENVIRONMENTAL PROTECTION- DEC 2 2003 o^ 5� TOWN CF ekiNBTABLE HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION MAP Property Address: P3.q kerI e PARCEL LOT Owner's Name: Owner's Address:. ��.�.P Date of Inspection: Name of Inspector: (please printjjcivalac A Browrl Company Name: Douglas A n Septic Inspections Mailing Address: RO Box 145 Telephone Number: r entervil", A 2632 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: V' Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: �i/`� Date: -10-26 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP_The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6.!15/2000 page ] �, , �«( ad /�� Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: &��i ���- -'I Owner's Name: Owner's Address:. Date of Inspection: fo—2-6-0j Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Sys tem Passes: have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments:- 4 PLC Ft) B. Conditionally Passes: one or more syst components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon pletion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y, , )in the following statements.If"not determined"please explain. The septic tank is metal and over 20 y old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfil 'on or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic approved by the Board of Health. *A metal septic tank will pass inspection if it is struc sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water leve ' the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box System>Vd f(withapproval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced The system required pumping more than 4 times a year due to broken or e system pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:_ � Vpf cc Dr�0 AA M �5 en 2r 10 Owner's Name: i1 a+4-eg,3 Owner's Address: Date of Inspection: J0_Q* �.. nation is Required by the Board of Health: Conditions exist 'ch require further evaluation by the Board of Health in order to determine if the system is failing to protect public h safety or the environment. I. System will pass unless Boa f Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a m r which will protect public health,safety and the environment:. _ Cesspool or privy is within 50 feet of a er _ Cesspool or privy is within 50 feet of a bordering vege d or a salt.marsh 2. ail un es s d of Health(and Public Water Supplier,if any)determines that the sy em is functioning in a manner tha tects the public health,safety and environment: _ the system has a septic tank and soil abso . n system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water ply. — The system has,a septic tank and SAS and the SAS is 'thin a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is wi 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 1 feet but 50 feet or more from a private water supply well".Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified lobo ory,for ooliform bacteria and volatile organic compounds indicates that the well is free from pollution t facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,Fovid no other failure criteria are triggered.A copy of the analysis must be attached to this form e . OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: , Owner's Name:_ 40. 0ta Owner's Address: Sr, P Date of Inspection:_ 10 — -26-(2am D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _Vackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _VDischarge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or Slogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _ Atk squid depth in cesspool is less than G"below invert or available volume is less than%2 day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped ✓Any portion of the SAS,cesspool or privy is below high ground water elevation- _ 1A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _ _AA Any portion of a cesspool or privy is within a Zone 1 of a public well. _ _kjA Any portion of a cesspool or privy is within 50 feet of a private water supply well. A Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Systems: T on ' ered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd You must indi a either`yes"or"no"to each of the following: (The following 'a apply to large systems in addition to the criteria above) yes no the system i within 400 feet of a surface drinking water supply the system is 'thin 200 feet of a tributary to a surface drinking water supply _ the system is locat in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public w pply well If you have answered"yes"to any question in E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The rator of any large system considered a significant threat under Section E or failed under Section D shall upgrade a sys with 310 CMR T Page 5 of 11 OFFICIAL INSPECTION.FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: AC Owner:- � y,J Date of Inspection: to Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No ¢/Pumping information was provided by the owner,occupant,or Board of Health ✓Were any of the system components pumped out in the previous two weeks? 1� Has the system received normal flows in the previous two week period ave large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined?(If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up ? Was the site inspected for signs of break out? Were all system components,excluding the SAS,located on site? tom. Were the septic tank manholes uncovered,opened,and the interior,of the tank inspected for the condition of the baffles or tees, material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes �o . Existing information.For example,a plan at the Board of Health_ !� Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: k1, 1 w �ily;�p AA 4 C92(i�iA Owner's Name: µj+*-o Owner's Address: ScArv,.p Date of Inspection: l.f'_ n f--©`3 RESIDENTIAL FLOW CONDITIONS Number of bedrooms(design): Number of bedrooms(actual):'3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): (� Number of current residents: 'I— Does residence have a garbage grinder(yes or no):N0 Is laundry on a separate sewage system(yes or no): tJ0[if yes separate inspection required] Laundry system inspected(yes or no):.N h Seasonal use:(yes or no):_6W QM 1 —9 S,pov dCA Water meter readings,if available(last 2 years usage(gpd)): q op,�- q�,O60 G, Sump pump(yes or no):yQ 3 Last date of occupancy: dte�.st C =senNt. DUSTRIAL:Type of Design flow(b on 310 CMR 15.203): end Basis of design fl (seats/persons/sgft,etc.): Grease trap present or no):— Industrial waste hold' present(yes or no):— Non-sanitary waste disc ed to the Title 5 system(yes or no): Water meter readings,if av Last date of occupancy/use: OTHER(describe): Pumping Records GENERAL INFORMATION Source of information: Was system pumped as part of the inspection(yes or no):N If yes,volume pumped:--_gallons--How was quantity pumped determined? Reason for pumping: TYP"F SYSTEM Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool Privy —Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from.system owner) —Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(ves or no): (l� Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:. P9Lv �r is de Owner's Name: A Owner's Address: Date of Inspection: 1(0-116-O'�) II,DING ocate on site plan) Depth below grade: Materials of construction:_cast iron 40 PVC other(explain): Distance from private water supply well or suc ' ' e: Comments(on condition of joints,venting,evidence of 1 g SEPTIC TANK:_(locate on site plan) Depth below grade:1')" / Material of construction: tt`oncrete_metal fiberglass Tpolyethylene other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions:_51*711X el&4 X q1/D'1 gyb )0 ) Sludge depth: T(c&c-e Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: d Distance from top of scum to top of outlet bee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): _(locate on site plan) Depth'below grade: Material of construction:— crete_metal fiberglass__polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet or baffle: Distance from bottom of scum to bottom of ou tee or baffle: Date of last pumping. Comments(on pumping recommendations,inlet and on or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): F Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: T)r�,l Ad nA.li s tQk� Owner's Name: Owner's Address: Date of Inspection: G (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete Infiberglass polyethylene other(explain): Dimensions: Capacity. gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping. Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Leoet wt4% 00kVe L- Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.):_ t`3 I v 0 P _(locate on site plan) Pumps in working order(ye no): Alarms in working order(yes or Comments(note condition of pump chain ndition of pumps and appurtenances,etc.): Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: [�,C 100P.1 ►/i'i'9 P Nl ,11c cnc�a� Owner's Name:_[};r Owner's Address: Date of Inspection: SOIL ABSORPTION SYSTEM(SAS):_(locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: leaching chambers,number: leaching galleries,number. leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: rr �innovative/alternative system Type/name of technology:_]W;hkjV6S q Continents(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): . CE S: (cesspool must be pumped as part of inspection)(locate on site plan) Number and corgi on: Depth—top of liquid to et invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on lan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic faflure,lev �diiig, onditio�Iofvegetation,etc.): Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: e fra"Z( Owner's Name•_ Owner's Address: Date of Inspection: /0w2&-0`S SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within.100 feet.Locate where public water supply enters the building. A 3 -2cf ec�c- O i 3 - — Z k _ Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: C Owner's Name: Owner's Address: Date of Inspection: SITE EXAM Slope% r eOet Surface water%NON'e Check cellar: ►Yes 'Ory Shallow wells NO Estimated depth to ground water 12.4—feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: I�Gwo -0_0005q5 „No. _, t Fee V 0 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01ppYication for Migpogar by.5tem Construction Vermit Application for a Permit to Construct( )Repair( 1<1pgrade( )Abandon( ) El Complete System r?fidividual Components Location Address or Lot No.FDV-CrrT Of Y4-p—y Owner's Name,Address and Tel.No. Assessor's Map/Parcel j_/n� 1 A N,wA c,,— Installe-'s Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design.Flow �O gallons per day. Calculated daily flow �`�cl gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank••,,��Le-t S`r f CD-117 i Type of S.A.S. , a C4 K:;_ Ut Description of Soil Ccs*,� 5.l ,p Nature of Repairs or Alterations(Answer when applicable) �Ac;rr Fcv- �S fit ti� Cv ( S ffc Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Enviro ntal Code and not to place the system in operation until a Certifi- cate of Compliance een issued by this o ea . Signe ate LV Application Approved by Date Application Disapproved fo the following reasons 44 Permit No. ` Date Issued TOWN OF BARNSTABLE LOCATION k' _ ,.may SEWAGE # 0 00 VILLAGE /n, ' i'llf ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. /7,rn Cif IJ2 2e, X / c_ SEPTIC TANK CAPACITY /d LEACHING FACILITY: (type) /. �7vt�rTc�/l_� (size) ✓ NO. OF BEDROOMS BUILDER OR OWNER PERMTTDATE: COMPLIANCE DATE: -tot r r Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge o.f:Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by i CA cA, I. i I 14lit- Q� -fib- z 711 Y / T (<I�h � o o No. ,Fee THE COMMONWEALTH OF MASSACHUSETTS i, Entered in computer. Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 2ppfication for Miopool *raem Construction Permit Application for a Permit to Construct( )Repair I.Kpgrade( )Abandon( ) ❑Complete System ItIftdividual Components ' Location Address or Lot No. f ft ! tc\( � Owner's Name,Address and Tel.No. Assessor's Map/Parcel ® U \\ A P Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 3 _Sc- gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank 4 ' `` «' Y° — Type of S.A.S. L C !X Description of Soil- C Yt V, C S Nature of Repairs or Alterations(Answer when applicable) 71'G-5-1 A-k\ �" AcG-r Fu.iz -�L-ivw. cc1 C CA, S-t6L-2_ d14- S V of C(tr Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Enviro ental Code and not to place the system in operation until a Certifi- cate_of Compliance ha Seeis ed by this Boar eat . Signed t? Date Application Approved by G� /' Date Application Disapproved for the following reasons r Permit No. Date Issued ----------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS - BARNSTABLE, MASSACHUSETTS (Certificate of compliance THIS IS TO CERTIFY, that.the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded(� ` Abandoned( )by i "C C at cJ v ✓ w c I , 1^I`a C has-Aem constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.bKM'-` Jdated Installer A Designer The issuance of this permit sh�a^ll t 'e constru as a guarantee that th�sy'ste w,1 function as destgned.1r / Date Inspecto � ��1, No.IT /t/ �l?J-�� -----------------------Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS ]Biopo,ar *patent (ton!5truction Permit Permission is hereby granted to Construct( )Repair(Upgrade( )Abandon( ) System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Constructio r must b (completed within three years of the date of a v` tt / Approved b Date: r ! / PP Y ,,� 1/6/99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL V WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) hereby certify that the application for dis posal works construction permit signed by me dated lt�yi q-o , concerning the property located at ��- �-e✓v 4 Q/ _ �r'tt;�� meets all of the following criteria: ✓This failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. .The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. X�- There are no wetlands within 100 feet of the proposed septic system ,ZThere are no private wells within 150 feet of the proposed septic system There is no increase in flow and/or change in use proposed • There are no variances requested or needed. s- The bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when a plicable] If theS.A.S.will e o S S. 1 b located with 250 feet of any vegetated wetlands,the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) B) G.W. Elevation V0.61+the MAX. High G.W.Adjustment. DIFFERENCE BETWEEN A and B 7 V " SIGNED : DATE: [Please Sketch prop plan o sys n back]. NOTICE Based upon the above information, a repair permit will be issued for bedrooms maximum. No additional bedrooms are authorized in the future without engineered septic system plans. q:health folder:cert 11 No.... y. FEs...S... ............... 'THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .............T.iN i............OF..... ..a Appliration for Disposal Works Tontrnr#ion Vrrmit Application is hereby made for a Permit to Construct (1/) or Repair ( ) an Individual Sewage Disposal A1System at 0 d'1e&/Z1zA �/Z i V :_ /I�?zS7vnrs /c1/LCs LoT .................r .... r.... --.............. ..... ......--•--...............................------.............------------..._......-------•--•---- Location-Address or Lot No. ,S7Z-'VLF Bk>W ............ ........_................._....._...... ...... .....-----•---•--�• •...... .........._...---•-------.....--------.......-•--------------------•-•----.....•---..._........•-- Owner ►� Address W a ......- ....... .................................................................................................. Installer Address d Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) PL4 Other fixtures ---------------•-----------.....- . W Design Flow......._.`'`'..............................gallons per person per day. Total daily flow...........Z3©__._....._._......___gallons. All WSept:c Tank—Liquid capacity.Zg?dU.gallons Length... Width-_4. .../_ Diameter................ Depth.—f_ x Disposal Trench—No.,.................... Width.................... Total Length_........_.......... Total leaching area.............._.....sq. ft. Seepage Pit No....._1__.__.____.. Diameter....f4.._..... Depth below inlet.... .`.......... Total leaching area..3Z S.sq. ft. Z Othe- Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by...... !P.!A/�........:....! L y..._...... Date__ ,aa Test Pit No. l.L.Zn....minutes per inch Depth of Test Pit....e ....... Depth to ground water....... Gi, Test Pit No. 2_2!�:_n....minutes per inch Depth of Test Pit....! .".... Depth to ground water........................ --•-••--••••••••-•-•.......................•.......------...................------•----------•----------•-----------------•--------------.........O Description of Soil.......�_�/=7z.:�._.wco7aLc S�lxr�y S'L,�-SoiG S�it�D v✓iY.Z/ G� U ...'/o ........6`/�A�/ Z /�f3 /.S Z Los�??�SG... �^' W ----------------------------------------------•-------------------------•-----.............-----...-----•--•------------------------------------•---------•--••---•-••-•-------.._..--------------....-- U Nature of Repairs or Alterations—Answer when applicable..............................................:................................................ --------------••-----••-•---•••----------------•--------•-------•-----..........----•---....--......----.....--••--•------•--•••----....--•-----•--•-----•------•-•-•-..............----•--------------• Agree;.nent The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed..............•--------••---•--•-•-•---•-----•--•--••---•------.._.......---•--....... ................................ Date Application Approved By............................................:...................... A Date Application Disapproved for the following reasons:------------------•------------•-----............-•-•--•----•--------------•----- - - ....................•----..................--•--•--------•-••----•---•-----••---••------..................--•--•------...........-•---------•----...---------------••----------------------------........ Date PermitNo......................................................... Issued....................................•................... Date I;11 No..... ... FEs... ............... THE COMMONWEALTH OF MASSACHUSETTS QOARD OF HEALTH ...........OF.....F.j ?2. 5.T�I./..�..G.1...................................... Appliration for Di,gpo,ial Work.5 Tonstrnrtion amit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at: ...... •--•.._..............••••......--••-•..........•••--- Location-Address or Lot No. ................... .......................................... ...................•...................-.... ........................................... WOwner Address ,-, *174?................ ..•-•------------------...............-•••-••••. .................................................................................................. Installer Address Type of Building Size Lot............................Sq. feet .-� Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) a� Other—Type of Building No. of g ............................ persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures ------------------------------------------------------........................................................................................... W Design Flow......... ..........................gallons per person per day. Total daily flow_........._llt?i0.....................gallons. W Septic Tank—Liquid capacity./oo._ca.gallons Length_.. ��' Width__4_4.... Diameter................ Depth. x Disposal Trench—No. .................... Width.....-.............. Total Length.................... Total leaching area..........-_........sq. ft. ..Seepage Pit No-------/. ,_____-- Diameter...../4�...... Depth below inlet....¢'........ Total leaching area..3Z.`P_:$.sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by...... .eA:Z4 :.. ........... Test Pit No. L.4.:_-Z.....minutes per inch Depth of Test Pit.... ._ ... Depth to ground water........................ IX4 Test Pit No. 2..4,..2-.___minutes per inch Depth of Test Pit---- Ste'"___. Depth to ground water........................ a -- ---------------------------------------------•----------...-.---•-•--•----------------------........--•------------.---------------------•-----.--------- O Description of Soil........Q��'.7 Z... �n!oy C.c�-st r�•�,Si�r�,l! S� -Soy G�• S dn.r� I.✓i1.... L4 U /� c17 ----------------7 . -�ot3-.. � .......................................... W •--------------•--------------------- --------- V Nature of Repairs or Alterations—Answer when applicable.....................................................................................:!......... -----------------------------------------------------------------------••...._..•-------.....-••••...........-•-•••-••-----•----•-•---•--•-••••••--•---------•-••-••...-•••-•-----•........--•-•........ Agreement: The undersigned agrees to install ,the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T I T U 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed...................................................................................... ................................ Date ApplicationApproved BY.................................................................................................. Date Application Disapproved for the following reasons-----------------------------•---------------------------------------------------------•--• --------...._..._. -•--------•-----------------•-----------------------------------•---------------------.......------......--•--•-----•--•--•-----•----•-•-•--•-•-•---••-•-----•---•------•------••-------•••---•--.....-- Date PermitNo......................................................... Issued-....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............ ..........OF........ ............................. Trrtif iratr of Tomplittnrr T O CERTIFY, That fii5individual wage Disposal System constructed (,,<or Repaired ( ) by- ........................ . -•--•-.....•-•-••••---••...--•-••-•••--•-•-.......--••-.._....••••••-•-•-••--••................ �/ Installer atQ1l.-•-- •----------•--•--------- has been installed in ac r nce with the provisions of TI -1 5 of The State Sanitary Code as described in the application for Disposal orks Construction Permit No....lS-V .46................ dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. a h w 4 .._....... Inspector...................................... DATE...----•-•..............•-----•...---- THE COMMONWEALTH OF MASSACHUSETTS .'BOARD OF HEALTH �>/- ..............wi. �.........OF......�.� .�� E- NO......................... FEE. .............. 15iiiposat orko notrnrt� n rrmtt Permission is hereby granted-----......r_.. ........... - ---------------------------------------------•-----.-•-.--------.-•--•----- to ConstruciL r Rep ( ) an n ividual Sewage Dis sal System at No........ .....//..r Street as shown on the a plicat' n fo Disposal Works Construction Permit N ..... ............. Datedf....____.__.................._........ Board of Health DATE -------•------------•-----------------------•---- FORM 1255 A. M. SULKIN, INC., BOSTON r = .SNE�T / vF Z SNEZT"s ti �r Ae z e 9. �oogo A7 oz. 1 Y • 1 LoT" // fox v s� \ Zv 3 S o Scpnc 77� 10 ZUV r'P «z 3 nPnePFosr-D ' A 4j t i h iSx. ` Ai Sep �yK p2 V Norr- EZ4Jvg770Ns d,k/ Si TE PLC .v ASScr.yEr7� �fl?t.�H. /� ScAGE /�a 40 A&8• PL,yN 2L-F- C&7,VC LaT d /� SNo wti on. L4vv T- PG-q� .3S-18LFf 8 SN /�C[�Ail>gy70A/ ,S/bwN ON 771/3 /� `j KELLEY !z CONFo2HS Wi7?/ J7/E JbT- E9cA: No.261U0 y �rr�c./e�tiit +vrs OF yW&- JVWAI O/STBP�O OF 4>2NSTXIQLt S U RVE�� r Z of Z ,SNG-'�3 TS _ TOP OF FOUNDATION CONCRETE COVER ., CONCRETE COVERS .4 �: 4'�CAST IRON 12"MAX. ' • PIPE (OR 411 ORANGEBURG(OR EQUIV.) 12"MAX. �•' EQUIV)— MIN. PITCH 1/4"PER. PIPE- MIN. LEACH PITCH 1/4"PER.FT. PIT PRECAST NVERT ° Q LEACHING '•e EL, 8308 „ INVERT INVERT w �;; PIT OR SEPTIC TANK DIST. EQUIV. e . EL.B?:7R 8Z.36 ' e INVERT BOX EL.. >_ 87 /o.aP.... GAL. 4•f=� �i' IEL ERT 8z,S3 INVERT w�,� : 3/4"TO I V WASHED , ' / •� w .�'� STONE • 141 DIA.:�!d ENi� 2urry PROR LE OF GROUND WATER TABLE SEWAGE DISPOSAL SYSTEM NO SCALE f- 3o3Z SOIL LOG WITNESSED BY : DATE : ;�/`8` . TIME.��:�d g!'� T44V. ,�;5 BOARD OF HEALTH TEST HOLE I TEST HOLE 2 �'1� , ENGINEER ELEV. . .87,11?. Mir sm, WoaDtosrwr, •y, j oaDzle SR"'°ys,08.s°•� �a" S "S°"�`' DESIGN DATA : tZ-BS:.¢tom S�wA Wry/ �yN Map,Si},ip 3 pac,re,rs —,a•B3^4i NUMBER OF BEDROOMS 71,' m' W rsw ibc A4dlTie 7 TOTAL ESTIMATED FLOW . .3 � , GALLONS/DAY cam' Cova d BOTTOM LEACHING AREA ��.3: `j. . SQ.FT, /PIT SIDE LEACHING AREA . . ./.7.- 9 . , . SQ.FT/ PIT /08 --Z. 7B,7o /oBu E.G 7B.¢o GARBAGE DISPOSAL . .Nc? . ..(50% AREA INCREASE) SAR.a N`�/gin TOTAL LEACHING AREA .3Z7. SQ.FT PERCOLATION RATE MIN/INCH ASb° .N.o.WATER ENCOUNTERED LEACHING AREA PER PERCOLATION RATE SQ.FT. NUMBER OF LEACHING PITS: 1. R!T,W; /Tt/, , APPROVED . . . . . . . . . . : BOARD OF HEALTHv'�• DATE . . . . . . . . . . . . . . . . . . . . . . . . AGENT OR INSPECTOR ' H OF Mgss�c �D ARD s. g 0 0 • lC�7z2 ?�,2/ KELLEY rY V L"i No.a No'26100 Z !'7zsTo�ys, eq�a/srea�`� PETITIONER ; .� YGr ,801nr�J,/ Q6. N�sueuEr saruaan�a I Massachusetts Water Resource�TOmmissipn/Divi�;on of Water Resources if WATER WELL OMVLETION REPORT • &WELL LOCATION) Address /` " / f' City/Town /¢rs .d ' S• _ G.S.Quadrangle Map Grid Location \�( Owner _S'Ae've opt Address If /r L USE CONSOLIDATED WELL Domestic Public ❑ Industrial❑ Type of Water-bearing Rock Other Water-bearing Zones METHOD DRILLED 1) From _ To Rotary(type)Cable❑ 2) From To Other 14 3) From To 4) From To CASING y` , Depth to Bedrock Length_Diameter Type UNCONSOLIDATED WELL STATIC WATER LEVEL Water-bearing Materials Feet below land surface _ s �. Sand: fine❑ medium coarse❑ i Date measured �—f — Gravel: fine❑ medium❑ coarse Screen: GRAVEL PACK WELL Slot# & ength j_from to Yes ❑ No 1 Split Screen(or 2nd screen) f WATER QU6UTY TESTS MADE Slog length from to Chemical Biological ❑ Depth To Bedrock PUMP TEST Drawdown A act after pumping days hours at l _ GPM. How measured Or14-x-Recovery feet after hours. LOG of FORMATIONS. fgMMENTS: (O �ll oryvater) Materials From To T Ae�/j'l r, / ®j n m IF t DR LLE�R ) Firm � _ /41y LVAr Address 10. City Aeo AIL + Registration No. `� 1 — per tors Signature Please print rrm y � 10M-8/81.184843